1. Scottish Antimicrobial Pharmacist Group SNAP-CAP& Empirical Prescribing Indicator Audit 8 th June 2010

2. NHS Borders : smallest mainland Health Board area in Scotland population 112760 Age >60years group is above Scottish average Increased incidence of hospitalization in older age groups. 1 district Hospital 293 beds

3. Audit Plan for SNAP-CAP Data collection/audit process Data collection/audit process Medical Admission Unit/ A&E Medical Admission Unit/ A&E Medical and nursing staff to capture appropriate patients Medical and nursing staff to capture appropriate patients Aim to collect 10 a month Aim to collect 10 a month Lead Antimicrobial Nurse to collect material for monthly update to IHI.org Lead Antimicrobial Nurse to collect material for monthly update to IHI.org Feedback to clinicians by poster/ email Feedback to clinicians by poster/ email

4. ….the story so far Data collection Data collection 2 referrals from A&E and then nothing 2 referrals from A&E and then nothing A few from MARU A few from MARU What ‘no pneumonias?’ What ‘no pneumonias?’ Review Review Raising SNAP-CAP/CURB65 profile Raising SNAP-CAP/CURB65 profile Active pursuit of CAP’s Active pursuit of CAP’s LRTI/Pneumonia: Data validated Respiratory Consultant LRTI/Pneumonia: Data validated Respiratory Consultant

5. CURB65: ‘I’ve heard of it’ Raising the profile of SNAP-CAP & CURB65 Raising the profile of SNAP-CAP & CURB65 Nursing/ junior medical staff education Nursing/ junior medical staff education Small group/ face to face interaction Small group/ face to face interaction Daily pursuance of pneumonias Daily pursuance of pneumonias Rising above the challenges of doctor rotations Rising above the challenges of doctor rotations Number of patients with CAP collected Number of patients with CAP collected Variable: 8-18 Variable: 8-18 Median monthly: 12 Median monthly: 12

6. Chasing CAP’s Active seeking of community acquired pneumonias Active seeking of community acquired pneumonias EDIS EDIS Checking notes/ admission board/ asking etc Checking notes/ admission board/ asking etc Unscheduled Care (BECS) Unscheduled Care (BECS) When is LRTI a pneumonia? When is LRTI a pneumonia? Reviewing X-ray reports Reviewing X-ray reports

7. ‘ITU have someone with CAP’ How the admission pathway actually operates! How the admission pathway actually operates! Patients requiring supported care e.g. CURB65=3 Patients requiring supported care e.g. CURB65=3 Ward 5 (High Dependency Care) Ward 5 (High Dependency Care) ITU aware ITU aware Feedback to medical teams Feedback to medical teams Where did that poster go? Where did that poster go? Opt-in email system for Junior Doctors Opt-in email system for Junior Doctors Micro site Micro site

9. Summary Greater awareness of SNAP-CAP/CURB65 Greater awareness of SNAP-CAP/CURB65 Consistency in data Consistency in data Time consuming Time consuming Change may impact on results Change may impact on results However, imperfect results / variability However, imperfect results / variability Challenge to improve implementation Challenge to improve implementation

10. Empirical Prescribing Indicator Audit Medical Acute Receiving Unit Medical Acute Receiving Unit 30 bedded unit 30 bedded unit High turnover of patients with infections High turnover of patients with infections Usually good compliance with recording of indication and prescribing within the local guidelines Usually good compliance with recording of indication and prescribing within the local guidelines Medical staff on hand, usually several. Medical staff on hand, usually several.

11. Surgical Acute Admissions Unit Surgical Acute Admissions Unit Small 11 bedded unit Small 11 bedded unit Some issues Some issues Challenge to capture 20 monthly Challenge to capture 20 monthly Indicator for antibiotic treatment not always clear Indicator for antibiotic treatment not always clear Do patients always require antibiotics? Do patients always require antibiotics? Medical staff not always present but nursing staff appraised of any issues Medical staff not always present but nursing staff appraised of any issues